URINARY SYMPTOMS IN MEN
Increasingly bothersome develop in many men as they get older in many men. These symptoms include poor urinary flow, delay at the start of the urinary flow and post urinary dribbling. Other symptoms include increasing frequency of having to visit the toilet both at night and during the day, together with urgency to get to the toilet. These symptoms can all be caused by a variety of conditions and some men perceive little bother, whereas others find they significantly impact on the quality of their life. These are the sorts of symptoms we can help to sort out as they may be related to diseases of the prostate, bladder or urethra.
Investigations usually include an assessment of the urinary flow rate and a bladder ultrasound test to check whether the bladder is emptying completely. Occasionally, bladder pressure tests are also required (cystometrogram/ Urodynamics). Assessment will also involve excluding prostate cancer as well as bladder cancer with examination and blood tests (PSA). Sometimes a telescopic examination of the bladder (flexible cystoscopy) is also advised
If the cause of the symptoms seems to relate to an enlarged prostate, often treatment with tablets is advised and in the majority of cases this will help the symptoms. For some men this medical therapy will not be enough and for them surgery may give much better relief of their symptoms. This surgery can be carried out using different techniques depending on the size of the prostate and other patient factors. Usually a TURP (trans-urethral resection of the prostate) achieves the best long-term results, and we usually use bipolar energy to operate with, which is a newer and safer technique.
Male urine infections are not as common as in women and can happen by chance or be a sign of an underlying illness. We often examine to see if there are signs of a bladder that is not emptying well or a kidney blockage. Infections can also affect the prostate or testis.
Though the initial treatment with antibiotics may resolve a problem it may also be necessary to carry out further tests to prevent problems recurring or to find the cause.
Whilst this is more common in women than men, it may often occur, more commonly as men get older. It is often possible to make a diagnosis and offer tablet treatment and/or physiotherapy as treatments for urine leakage once a diagnosis has been made. Sometimes it is a sign of the bladder not emptying properly and urine leaks as it overflows from the bladder
Urine problems may also be a sign of prostate or bladder cancer, although for men who are under 40 this is less likely. Prostate patients with prostate-related symptoms may need a PSA blood test with further investigations such as MRI and or biopsies to clarify the situation.
Prostate UK has good background advice but we strongly suggest patients see a specialist to diagnose which prostate problems may be affecting you and advice for treatment if necessary.
We can provide state of the art template biopsies and MRI scanning as a guide to decide if there are any suspicious areas in the prostate if appropriate.
Most problems which are not related to a cancer diagnosis can be sorted out with medication. If surgery is needed it is usually offered with a short stay of one to two nights in hospital
Support information from the British Association of Urological Surgeons.
HAEMATURIA (Blood in pee)
Haematuria is defined as the presence of blood in the urine. It is either visible (frank) or non-visible (microscopic). It has many causes including: infection in the bladder or kidneys or prostate (often associated with pain or discomfort on passing urine), Stones in the urinary tract, Bursting of a small blood vessel, a tumour (cancer) in the bladder, kidneys or ureters,
Sometimes non-visible haematuria can be caused by some disorders of the kidney usually investigated by a nephrologist.
Most people who pee blood would probably think that this was a little worrying. Sometimes blood in the urine can be the first sign of a really important problem such as a bladder or kidney cancer. These problems are more common in current or ex-smokers but even people with a healthy lifestyle may have them. For many people however it is not associated with any major illness and may go away on its own. Because you as a patient can't tell if blood in your pee is important or not you are encouraged to report it to your doctor urgently. If you see your GP with this problem they are likely to do a urine test to check for infection and antibiotic treatment may be needed if this is the cause.
A urine test and blood tests are usually required to rule out infection and ensure that the kidney function is normal. The kidneys are examined with ultrasound and CT scans if required and a flexible camera is used to examine the bladder under a local anaesthetic (called a flexible cystoscopy). These tests will usually demonstrate the cause of the bleeding and your treatment options will be discussed with you after these tests. Occasionally, further tests are required.
Often the all clear is given and no long term follow up is needed, but if a serious condition is diagnosed then keyhole surgery for kidney and bladder problems can be offered and laser vaporisation of kidney stones can be performed if required.
MALE UROLOGY CANCERS
Male cancer problems are a significant part of urology and most commonly (except testicular cancer) affecting older patients (except testicular cancer).
PROSTATE CANCER AND PROSTATE CANCER SCREENING
Prostate cancer is the most common male cancer in the UK with over 10 000 new diagnoses made yearly. It presents most commonly in older men. It is uncommon in men under the age of 50 years and may be suspected because of urinary symptoms or a raised prostate cancer blood test (Prostate Specific Antigen or PSA).
PSA is only produced by the prostate gland and is commonly raised in prostate cancer. It may also be raised in other non cancer related prostate conditions but if over the recommended age related level it represents a higher risk of prostate cancer. The prostate is situated near the rectum and is examined by placing a finger in the rectum. If the prostate feels firm or clearly nodular, a cancer may be suspected. A raised PSA or abnormal feeling prostate can represent a higher risk for prostate cancer.
Many men have PSA testing done via their GP if it is suspected. If a result is abnormal or the GP has examined the prostate and thought it may be abnormal men may be referred for assessment.
We will conduct a careful assessment to determine your risk of prostate cancer and from that determine whether to investigate further. These investigations may include repeating the PSA blood test, obtaining a multi-parametric MRI scan of the prostate, or performing a biopsy or sampling of the prostate. In some instances a PCA3 test can be useful. We can offer state of the art transperineal template biopsies of the prostate as well as the more standard trans-rectal biopsies of the prostate. The samples are then examined under a microscope by a specialist pathologist to see if there is harmless benign enlargement of the prostate or cancerous enlargement.
Not every man with prostate cancer requires treatment and in some cases active surveillance is appropriate. This means that the cancer is of low risk and rather than having a treatment with side effects, a close eye is kept on the prostate with regular PSA blood tests and periodic repeat biopsies. If the prostate cancer is one that requires treatment we will be able to guide you towards the best treatment options for you. We have close links with colleagues in London who carry out robotic radical prostatectomy surgery
Advanced prostate cancer is treated by switching off the male hormone, testosterone, thus removing the driver that makes prostate cancers grow. This can involve daily tablets or 3 monthly injections.
Testicular cancer is now highly curable due to treatments that combine surgery and for men with more severe disease on some occasions chemotherapy. Men who are suspected of having this condition usually see a urologist for blood tests and an ultrasound assessment is usually performed. If these suggest testicular cancer the tumour can usually be removed, often as single day surgery for early problems.
About 10,000 people a year in the UK get bladder cancer. It is more common in men than women and rare below the age of 50 years. Cigarette smoking is the biggest risk factor although often there does not appear to be any obvious cause. Transitional cell carcinoma is the commonest type of bladder cancer. Most cancers occur just on the lining on the inside of the bladder. Sometimes they grow deeper into the muscle of the bladder wall and become invasive in which case their management is more complicated. Carcinoma-in-situ is an aggressive type of bladder cancer that again occurs just on the surface but has a higher risk of becoming invasive if untreated.
How is Bladder Cancer Diagnosed?
If your GP is concerned, you will be referred to a urologist for further tests. A general assessment will be carried out, including a prostate check in men. Sometimes, your urine will be tested with a special NMP22 bladder check test immediately in the clinic- this test detects abnormal proteins in the urine and gives a good early indication that there might be a bladder cancer present. Usually blood tests are arranged including tests of kidney function and a PSA test. Scans of the kidneys are also arranged and the most important test is a cystoscopy. This is where a camera is inserted into the bladder and takes a few minutes but allows excellent views of the inside of the bladder.
How is Bladder Cancer Treated?
If a bladder cancer is discovered during the initial tests the next step will be to arrange an admission to Springfield Hospital or one of the hospitals in which we work, for an operation. Under a general anaesthetic ‘key hole’ techniques are used to pass an instrument through the urethra and scrape away the tumour with a hot wire loop. After the operation a catheter is required to drain the urine for one or two days until it clears. Specimens obtained are sent away for analysis to determine what sort of tumour was present and how deeply it has spread into the bladder wall. Most tumours are just on the surface lining of the inside of the bladder so this initial operation will cure the problem although they have a tendency to recur so regular follow up bladder checks will be required. Often a solution called Mitomycin is instilled into the bladder for an hour after the surgery to try and prevent these recurrences in the future.
What if the Cancer is more Advanced?
Cancers that appear to be more aggressive but haven’t put down roots– so called high grade G3pT1 or CIS- often require a course of weekly bladder instillations with a substance called BCG. This is put into the bladder with a temporary catheter and again needs to be retained for about 2 hours . Tumours that are found to invade deeply into the wall of the bladder will require further treatment either in the form of radiotherapy or surgery (a cystectomy) to remove the bladder (a cystectomy). A course of chemotherapy may be given first to shrink the tumour. If the bladder does have to be removed then the urine will be brought out into a bag that attaches to the skin of the abdomen (a urostomy). Alternatively a new bladder using the patient’s bowel can be constructed so that they can void the normal way after the operation (a bladder reconstruction or neobladder).
Kidney cancers are increasing in incidence due to improvements in and increased access to Ultrasound and CT scanning. They are more common in men than in women by a ratio of 2:1. The commonest age to present with the disease is between 60 and 80. People with a rare genetic condition called von Hippel Lindau disease develop tumours at an early age.
The majority of kidney cancers are treated with surgery. Laproscopic (Keyhole) renal surgery is usually possible, but open radical nephrectomy (kidney removal) remains necessary in a number of cases. Treatment is dictated by a number of factors including age, other health problems, size of the tumour, number of tumours and the condition of the other kidney. Kidney sparing surgery (Partial Nephrectomy) is sometimes appropriate.
Tumours not amenable to partial nephrectomy, with a normal contralateral kidney may be treated with a laparoscopic radical nephrectomy or open radical nephrectomy if not suitable for key hole surgery. Small tumours may be removed from the kidney . Partial nephrectomy can be performed with a key hole technique but may require open surgery. Other options for small and occasionally multiple tumours, include cryotherapy (freezing of tumour) and radio frequency ablation (heating of tumour).
Often small incidentally found lesions in the elderly, may only require treatment if they become symptomatic. Blood in the urine can be dealt with by blocking the blood supply of the tumour, this is performed by imaging specialists called radiologists.
We are able to offer surgery locally for patients who require either removal of the kidney or part of the kidney (partial nephrectomy). In some cases cryotherapy for small kidney cancers is an appropriate treatment and this can be offered locally as well.
BENIGN KIDNEY PROBLEMS
Renal cysts are present in over 50% of the population over above the age of 50, this was unknown until the advent of widespread renal tract USS. Simple cysts make up 70% of the benign renal masses and seldom require treatment. Solid benign masses include oncocytomas and angiomyolipomas (AML). Oncocytomas are difficult to distinguish from malignant tumours and are therefore usually removed, if found no follow up is required. AML occur sporadically but 20% are associated with tuberosclerosis, a rare genetic condition. They are composed of blood vessels, smooth muscle and fat. When they become greater than 4cm, due to the risk of haemorrhage, treatment is usually recommended with either embolization or surgery.
Laparoscopic and Robotic Surgery
The word laparoscopy means to look inside the abdomen with a camera or scope. Surgery performed with the aid of these cameras is known as keyhole or minimally invasive surgery. The technique of laparoscopic surgery is now well developed in the field of urology and is now performed routinely for benign and malignant kidney conditions and pelvic cancer surgery. The advantages of this technique are smaller surgical wounds resulting in less pain, lower infection risk and reduced, pain-killer requirements and so a faster return to normal activities including less time off work. The technique is arguably more precise given the magnified view that the cameras offer. Laparoscopic procedures offered by Mr Nuttall include laparoscopic or robotic nephrectomy, pyeloplasty, and varicocele ligation.
The da Vinci Surgical robotic system (http://www.davincisurgery.com/urology/) allows complex surgical procedures to be performed using minimally invasive techniques. Broomfield Hospital in Chelmsford is one of only a handful of hospitals in the country to have this system. It is used for urological procedures as well as complex surgical procedures from other surgical specialities.
SCROTAL LUMPS AND BUMPS
SCROTAL LUMPS AND BUMPS IN MEN
It is not uncommon for men to find lumps in the scrotum. Most commonly these are not alarming but occasionally can be a sign of testicular cancer.
More commonly the lumps are due to conditions such as hydrocele or epididymal cysts
We can offer rapid diagnostic assessment with ultrasound and if necessary surgery to resolve the problem.
These operations are usually carried out under general anaesthesia as a day case operationprocedure.
The following links below are to BAUS leaflets
PAINFUL CONDITIONS IN MALE UROLOGY
There may be occasions after previous infection, surgery or injury that painful conditions for men occur in the urological organs, for example, penis, testicles, bladder or prostate.
If your GP thinks one of these organs could be causing pain then they may refer you to a urologist.
Testicular pain is very common and has many causes. These include, infection, previous surgery, tumours in the testicle, or pain radiating to the testicle from elsewhere in the body. A careful history and examination is required. Almost always an ultrasound examination of the testicles will also be needed. Treatment very much depends on the underlying cause and ranges from reassurance, to tablets and in some cases surgery. Close liaison with other medical specialists including those in radiology and pain clinics is sometimes required.
Sometimes the prostate is the source of the pain. Either inflammation or infection in the prostate can cause prostatitis. This can present as pain in the perineum – particularly when sitting down, or with urinary difficulties. We are able to offer rapid assessment and treatment of this problematic diagnosis. We have well established links with Consultant colleagues within the Pain service on the occasion that standard treatments are unsuccessful.
Support information from the British Association of Urological Surgeons.
MALE SEXUAL HEALTH
Erectile dysfunction is the persistent inability to either achieve or sustain an erection. About 5-20% of men have moderate or severe erectile dysfunction. There are many causes and risk factors including lack of exercise, smoking, diabetes, raised cholesterol, obesity and the metabolic syndrome. Sometimes it relates to previous pelvic surgery or to penile deformities. Investigations include careful history and examination and blood tests. Treatment depends on the cause. Pro-erectile drugs (phosphodiesterase type 5 inhibitors eg Viagra) are often the first line, but these need to used carefully and correctly. If these fail, other treatments are available including vacuum constriction devices, penile injections or surgery using penile prostheses.
We have extensive experience in assessing this sometimes embarrassing problem and initiating appropriate treatments.
Peyronies disease causes lumps in the penis, a bend in the erection and often painful erections.
It is not uncommon for the penis to bend slightly when erect. Sometimes the amount of bend can be excessive which may cause pain or difficulty having sex. The reasons why this condition develops are not fully understood
The disease usually progresses over a period of several months, then stops getting worse. The pain settles, but the lumps and the bend remain as they are. No drug or treatment has been shown to reliably treat the problem. However, once the disease has stopped progressing the bend in the erection can be straightened by surgery. There are, however, risks of side effects and complications from surgery. We will conduct a careful assessment to advise you on which operation may be the best option for you.
Low testosterone, also known as hypogonadism or Andropause, affects roughly 40% of men over the age of 45 and increases with age.
What are the signs of low testosterone in men?
There are both sexual and non-sexual signs and symptoms associated with low testosterone. Sexual symptoms include poor erectile function, low libido (desire for sex) together with weaker and fewer erections.
Nonsexual symptoms include increased body fat, decreased energy and fatigue, reduced muscle mass, and depression.
Roughly 40% of men with high blood pressure and 40% of men with high cholesterol levels will have low testosterone levels.
What are the treatment options for men with hypogonadism?
There are many treatment options for low testosterone if it is causing problems. Testosterone replacement therapy may be in the form of skin gel, injections, long acting pellets, or patches. The most common type of therapy is gel therapy, which is used by approximately 70% of patients. Men simply rub a gel onto their shoulders or upper arms after taking a shower.
Men treated with testosterone may be at an increased risk for the development or worsening of urinary symptoms.
Long-term treatment with testosterone may impair a man's fertility as it suppresses some of the remaining natural function of the testes. Testosterone should not be used in men with known or suspected prostate cancer. It is important to carry out regular blood tests to monitor the treatment.
VASECTOMY AND VASECTOMY REVERSAL
When couples want a permanent form of contraception a vasectomy is an option that may be considered.
A vasectomy is an operation to cut and seal off the tubes (called the vasa deferentia) that carry sperm from the testicles to the penis. Having a vasectomy means you will not be able to father any more children. The operation can be done with you either asleep under general anaesthesia or awake under local anaesthesia. It is important to provide two semen samples
after at 3 and 4 months following the operation to determine that it has been successful.
Vasectomy can be reversed but it should be considered a permanent form of contraception. Mr McAcallister carries out the operation of vasectomy reversal at the Chelmsford Urology Partnership.
Support information from the British Association of Urological Surgeons.
Kidney stones make up the majority of stone disease in the UK but bladder stones still occur, usually in men whose bladders empty incompletely of urine do not empty of urine completely. Stones occur most commonly in the 20-50 age range, but can affect any age group. Men are affected more commonly than women and stones occur more frequently in the summer. In the UK 1 in 10 will suffer with a kidney stone by the age of 70. Most stones are formed of calcium combined with other chemicals, most commonly phosphate and oxalate. There is a high risk of forming further stones, once one has occurred.
Risk factors for stones include:
Low fluid intake, high protein diet, Low calcium diet (Calcium in the diet binds to oxalate and phosphate preventing absorption), Diabetes, Obesity, Rare genetic conditions e.g. Cystinuria
Stones form in the kidney and if they pass out of the kidney into the tube connecting the kidney to the bladder (ureter) pain usually occurs. This is known as “Renal Colic”. The pain is often agonising and comes in waves and patients often cannot get comfortable. Most small stones will pass on their own given some time, but others will not. Many stones may will not cause symptoms if they remain in the kidney but they. Kidney stones may be a cause of blood in the urine and recurrent urine infections.
Most stones are visible on a plain x-ray, known as a KUB. The use of CT scans is becoming more common as it is very good at detecting stones and does not require an injection. We have recently adopted the use of “ultra-low dose” CT scans designed to minimise the dose of radiation received, whilst still being able to visualise stones.
The majority of stones that cause symptoms by passing down the ureter, do not require surgical treatment. 85% of stones less than 4mm will pass spontaneously. Medicines can be given to relieve pain and help with the passage of the stone. Stones within the kidney, can be treated with shockwaves generated by a machine. This is known as Extracorporeal Shock Wave Lithotripsy (ESWL). The patient lies on a couch and the machine is placed against the back. Treatments may last for up to 1 hour, patients may require pain killers during the procedure. The number of treatments required depend on the size, type and number of stones. Some patients require the placement of a ureteric stent before treatment, this is a plastic tube running from the kidney to the bladder placed under a short general anaesthetic.
Stones may require surgical removal. This is usually performed endoscopically, using a rigid or flexible camera passed via the bladder to the stone (Ureteroscopy). Stones may then be removed intact with a basket or broken up into fragments with a laser or shockwave machine. Larger stones in the kidney may need to be removed by a “keyhole” technique with a direct puncture into the kidney, this is known as Percutaneous Nephrolithotomy (PCNL).
We have access to all state of the art treatments for stones including laser treatment to vapourise stones and shock wave therapy (Extracorporeal shock wave lithotripsy: ESWL)
Support information from the British Association of Urological Surgeons.